Cycle 1
Health 2024-01-11 · Fire 2024-01-11
8 health deficiencies
Top issue: Environmental (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
East Greenbush, NY
Evergreen Commons Rehabilitation And Nursing Ctr
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1070 Luther Road, East Greenbush, NY
(518) 479-4662
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
233
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1972-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.03
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,730
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9918
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.64
Baseline 19.75% · Performance 18.36% · Measure score 6.64 · Achievement 6.64 · Improvement 4.62
Healthcare-associated infections
4.91
Baseline 6.28% · Performance 6.37% · Measure score 4.91 · Achievement 4.91 · Improvement 0
Total nurse turnover
2.07
Baseline 36.88% · Performance 55.20% · Measure score 2.07 · Achievement 2.07 · Improvement 0
Adjusted total nurse staffing
1.90
Baseline 3.13 hours · Performance 3.62 hours · Measure score 1.90 · Achievement 1.90 · Improvement 1.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.88% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 9.7% · Lower 95% interval 7.65% |
| Discharge to community | 38.11% |
50.57%
12.5 pts worse
|
Worse than the National Rate · Eligible stays 236 · Observed rate 29.66% · Lower 95% interval 31.27% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 165 · Denominator 165 |
| Falls with major injury | 1.21% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 165 |
| Discharge self-care score | 32.33% |
53.69%
21.4 pts worse
|
Numerator 43 · Denominator 133 |
| Discharge mobility score | 36.84% |
50.94%
14.1 pts worse
|
Numerator 49 · Denominator 133 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 6 · Denominator 165 · Adjusted rate 4.03% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 6.67% · Lower 95% interval 4.26% |
| Staff COVID-19 vaccination coverage | 1.37% |
8.2%
6.8 pts worse
|
Numerator 4 · Denominator 293 |
| Staff flu vaccination coverage | 63.5% |
42%
21.5 pts better
|
Numerator 207 · Denominator 326 |
| Discharge function score | 40.6% |
56.45%
15.9 pts worse
|
Numerator 54 · Denominator 133 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 62 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 29 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
91.2%
3.8 pts worse
|
93.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.4% · Q2 88.4% · Q3 88.2% · Q4 85.7% · 4Q avg 87.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
95.3%
3 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.0%
0.1 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.2% · Q3 2.4% · Q4 1.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.1%
2.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 2.3% · Q4 2.8% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.8% |
13.5%
7.7 pts better
|
19.6%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.0% · Q3 5.3% · Q4 6.3% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.3% |
14.8%
13.5 pts worse
|
16.7%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 28.3% · Q3 29.8% · Q4 26.3% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.8% |
15.1%
3.3 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 11.9% · Q3 13.6% · Q4 8.9% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
15.5%
1.9 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 17.3% · Q3 11.9% · Q4 13.0% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.6%
0.5 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.4%
0.1 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.4% · Q3 1.4% · Q4 1.9% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.6% |
20.8%
10.8 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 29.8% · Q3 34.5% · Q4 23.1% · 4Q avg 31.6% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
6.9%
0.8 pts better
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.7% · Q3 6.7% · Q4 3.5% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.9% |
76.7%
3.2 pts better
|
81.7%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 75.0% · Q3 74.8% · Q4 82.9% · 4Q avg 79.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
9.7%
4.1 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 13.3% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.8% |
78.8%
5 pts better
|
79.7%
4.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
20.6%
1.9 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 16.7% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-01 · Fire 2021-09-01
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-08-26 · Fire 2019-08-26
6 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-01-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-05
E · Potential for more than minimal harm
2021-09-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-10-19
E · Potential for more than minimal harm
2021-09-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-19
E · Potential for more than minimal harm
2021-09-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-10-19
E · Potential for more than minimal harm
2019-08-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-25
E · Potential for more than minimal harm
2019-08-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-01-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-01-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-12
E · Potential for more than minimal harm
2024-01-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-01-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-01-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-11
D · Potential for more than minimal harm
2024-01-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-04-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-19
E · Potential for more than minimal harm
2021-09-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-10-19
D · Potential for more than minimal harm
2021-09-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-10-19
D · Potential for more than minimal harm
2021-09-01
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-10-19
D · Potential for more than minimal harm
2019-08-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-08-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-25
Penalties and ownership
What sits behind the stars
Ownership
Koenig, Uri
5% Or Greater Direct Ownership Interest · Individual
Steif, Efraim
5% Or Greater Direct Ownership Interest · Individual
Steif, Efraim
Operational/Managerial Control · Individual
Wuertzer, Amy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Rosewood Rehabilitation And Nursing Center
Rensselaer, NY
2-star overall rating with 2-star inspections with $31,815 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
St Margarets Center
Albany, NY
3-star overall rating with 2-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Hudson Park Rehabilitation And Nursing Center
Albany, NY
1-star overall rating with 1-star inspections with $9,750 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out